Contribution to Diagnosis Chief complaint CC CC HPI

Contribution to Diagnosis

Chief complaint : CC

CC , HPI • CC= chest pain • HPI ü The pain began 1 month ago and only occurs with activity. It rapidly goes away with rest. When it does occur, it is a steady pressure focused on the center of the chest that is roughly a 5 (on a scale of 1 to 10). Over the last week, it has happened 6 times while in the first week it happened only once. The patient has never experienced anything like this previously and has not mentioned this problem to anyone else prior to meeting with you. As yet, they have employed no specific therapy.

(PMH) Direct Questions Ø Diabetes Ø Asthma Ø Jaundice Ø Rheumatic fever Ø TB Ø Hypertension Ø Epilepsy Ø CVA/ MI

Social History ADL= Activity Daily living activities that are necessary for daily care of oneself and independent community living. It includes using the toilet and grooming, dressing, and feeding oneself; independent community living includes driving, shopping, homemaking, care of family, work activities, and so o

Drug History=DH Atenolol 50 mg/day qd: once a day -“daily” bid: twice a day tid: three times a day qid: four times a day q. HS: every evening (HS = hora somni, or hour of sleep) • prn: as needed • NPO (nothing by mouth) • IV/IM § • • •

Allergies/Reactions • Allergies/Reactions

• REVIEW OF SYSTEMS

G C Yes No Don’t know please write details: 1 -Unexplained Wight loss 2 -Unexplained Wight gain 3 -Chronic fatigue 4 -Change in appetite 5 -Night sweats 6 -Fever or chills if yes

Gastrointestinal Review Ø Appetite Ø Taste Ø Swallowing Ø Heartburn Ø Vomiting Ø Bloating/ belching Ø Abdominal pain Ø Post-prandial symptoms Ø Bowel habit Ø Change in bowel motion , color, consistency, blood or mucous

Cardio-vascular review Ø Chest pain Ø Palpitations Ø dyspnea Ø Cough - sputum Ø Ankle swelling Ø Exertional symptoms

respiratory review

Urogenital review Ø groin pain Ø Micturation üdysuria üurgency, frequency, nocturia ühesitancy, stream, dribbling ühaematuria, pneumaturia üchange in colour/ smell of urine

Gynaecological review Ø Menses Ø Pregnancy Ø PV discharge Ø Post-menopausal bleeding Ø Contraception Ø Dyspareunia Ø Obstetric history

Neurological review Ø Loss of consciousness Ø Loss/ blurring of vision/ speech Ø Loss of power Ø Loss of balance Ø Parasthesia Ø Headache Ø Tremor Ø Behavior/ mood

Orthopaedic review Ø Limb pain Ø Joint pain Ø Limitation of movement Ø Weakness Ø Disturbance of gait

Vascular review Ø Neurological symtoms Ø Abdominal back pain swelling Ø Claudication Ø Limb pain Ø Colour change Ø Pigmentation Ø Limb temperature

PHYSICAL EXAMINATION

General Appearance=GA • 1 -Apparent state of health? 2 -Signs of distress • 3 -Level of consciousness 4 -Skin color and obvious lesions? • 5 -Odors of the body and breath? 6 -Facial expression?

Vital signs=VS • • T Temperature: oral axillary HR Radial pulse: number rhythm RR Respiratory rate: number rhythm BP Blood pressure: left arm right arm H Height W Weight BMI

PE • Skin • HEENT • NECK • Chest • Abdomen • LIMB

• Problem list

• Diffrentional diagnosis:

• Plan:

• • • Cc HPI PMH DH SH&PH ROS PE Para clinic Problem list DD Plan ﺧﻼﺻﻪ

Special Types of History ü The trauma patient ü The unconscious patient ü The demented / psychologic patient ü Emergent Patients ü Outpatient

Presenting a History Ø Look smart Ø Speak clearly Ø Mention important negatives Ø Try not to use notes